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Based on observation, interview and record review the facility failed to ensure patients received care in an safe environment in that they failed to ensure its own Policy and Procedures were enforced for daily checks of emergency carts for 1 of 3 carts observed (cart # 19) and the required emergency suction equipment was not available on 2 of 3 crash carts observed (Carts #41 & 57).

Findings Include:

Policy reviewed:

Review of the facility's current Policy and Procedure titled: Cardiopulmonary Resuscitation (CPR)/Emergency Cart; Publication Date 05/19/2016; Version 2. Purpose: The purpose of this document is to outline the procedures that need to be followed in the event of a medical emergency/CPR.

Procedure: 1. It is the policy of Memorial Hermann Greater Heights Hospital to provide qualified personnel and necessary equipment to treat life threatening emergencies throughout the hospital.

III. Cardiopulmonary Resuscitation: A. Hospital personnel on the scene are responsible for properly positioning the patient and opening the airway in anticipation of CPR. D. The following will be done by personnel available at the scene: 6. Oropharyngeal suctioning as needed.

IV. CPR Emergency Cart: D. 1. The Emergency Cart is checked daily for: a. if closed, write closed on the audit form for that particular date; a. Cart lock security; 2. Defibrillator/Monitor will be tested (unplugged) daily. 3. The following is documented on the CPR Emergency Audit Record. c. Joules used to test defibrillator, d. Initials and signature of person doing the checks.

Observation of the mobile "MRI" unit on 5/23/2019 at 10:30 a.m. along with Quality Manager Employee ID #A and Director of Imaging Employee #K revealed an emergency crash cart(#19) located inside the mobile MRI Unit. Review of document found on top of the Emergency Cart, titled "Emergency Cart Audit Record" documented a completed log for the dates of May 1 - 22, 2019. All entries were signed as being completed by Employee ID #M. May 23, 2019 had a signature by Employee ID #M, none of the required Emergency Cart daily checks were completed. Audit Record did not include the required employee's initials and joules used to test the defibrillator.

Interview with Employee ID #M at 10:45 a.m. along with Employee ID #A and #K confirmation that Employee ID #M had completed the daily Emergency Cart Audit Record for the previous dates of May 1 - 22, 2019. Employee ID # M was asked if that was his signature on May 23, 2019 line and he stated yes, when ask why none of the emergency cart required information safety checks were filled out he stated that he always does the emergency cart checks at 6:30 a.m. and must of forgot to fill in the other information. Employee ID #M was asked to demonstrate testing of the defibrillator, this demonstration was observed also by the Quality Manager and Director of Imaging. Employee ID #M failed to unplug defibrillator/Monitor prior to testing.

Interview with the Director of Imaging, Employee ID #K on 5/23/19 at 2:00 p.m. revealed when ask if Employee ID #M had worked 23 straight days as demonstrated by his signature for the dates of May 1 - 23, 2019 on the Emergency Cart Audit Record . Employee ID #K confirmed that Employee ID #M had not worked 23 day straight and was a manager and only worked Monday through Friday. Employee ID #K does not know why he would of sign the Emergency Cart Audit Sheet for the days he did not work. No additional information was provided.

Review of the policy and procedure titled "Cardiopulmonary Resuscitation (CPR)/Emergency Cart with the Manager of Quality Employee ID #A confirmed the Audit Record did not include the required employee's initials, joules used to test the defibrillator and suction machine check.

During a tour of the facility on 5/23/2019 at 10:30 a.m. along with the Quality Manager, Employee ID #A. Three Emergency Crash Cart were observed. Emergency Crash Cart ID #s 19, 41 and 57. Two Emergency Crash Carts did not contain a emergency suction machine (Carts #41 & 57).

1. Observation on 5/23/2019 of the Emergency Crash Cart located in the Imagining Department along with the Quality Manager, Employee ID #A Crash Cart ID #41 was observed to have no emergency suction machine.

Interview with Employee ID #Q confirmed there was no suction machine currently on the crash cart. When asked if there was usually a emergency suction machine on the cart Employee ID #Q replied there was one, but the Imaging Director, Employee ID #K just came a little while ago and took the suction machine to the MRI trailer.

2. Observation on 5/23/2019 of the 4th floor medical unit along with the Quality Manager, Employee ID #A and Patient Care Director ID #F the Crash Cart ID #57 was observed to not have a emergency suction machine.

Interview with Quality Manager ID #A on 5/23/2019 at 4:15: p.m. confirmed the emergency crash carts in the Imaging Department and the 4th floor did not have suction machines. Employee ID #A stated that all patient rooms and imaging rooms contain suction equipment and confirmed the hospital did not have enough suctioning equipment for all crash carts. When Employee ID #A was asked if an emergency response was needed and the individual was not in a patient room with suction available how would the hospital respond if there was no emergency suction machine was on the emergency cart. Employee ID #A responded that suction was available in the patient rooms.

Further information received by email on 5/29/2019 from Employee ID #A confirmed the facility had a total of 64 crash carts and 23 suction machine and stated, "We are in the process of renting machines and prioritizing crash carts that do wall suction."